Massage Therapy SOAP Notes

What, exactly, are massage therapy SOAP notes? How are they written? And how can massage therapists use SOAP notes to improve their practices—both for themselves and their clients?

What are SOAP notes for massage therapy?

Before we jump into how SOAP notes can benefit your practice, let’s quickly cover what massage therapy SOAP notes are.

“Massage therapy SOAP notes are a systematic way of documenting the assessment and treatment of clients,” says Michael Jones, MS, a massage therapist and posture and ergonomics expert with nearly 20 years of experience. “SOAP notes provide a clear, structured format for tracking client progress and ensuring continuity of care.”

SOAP notes are broken down into multiple sections that allow massage therapists to assess and treat clients. 

There are a number of different ways therapists may use massage therapy SOAP notes in their practice.

For example, in Jones’ practice, “SOAP notes are integral to ensuring that each session is tailored to the client’s needs and progress.”

SOAP notes can also help massage therapists track their clients’ progress over time—and adjust their treatment approach, as needed.

“I start by reviewing the previous session’s notes to understand where we left off,” says Jones. “During the treatment, I use SOAP notes to document any changes in the client’s condition, my observations, and the techniques used. This helps me adjust my approach as needed and ensures that I’m always working towards the client’s goals.”

By continuously tracking, assessing clients, and adjusting treatment plans, massage therapists can provide a higher level of care to their clients.

“SOAP notes have significantly enhanced the quality of care I provide,” says Jones. “They ensure a high level of consistency and continuity between sessions, allowing me to build on previous treatments effectively.”

SOAP notes are also helpful from a collaborative perspective. “SOAP notes are invaluable for communication with other healthcare professionals, as they provide a clear and concise summary of the client’s treatment and progress,” says Jones. This ensures clients receive coordinated and comprehensive care from their providers.

Finally, SOAP notes can give massage therapists invaluable information on their treatment approach—information they can use to continually improve and evolve as therapists. 

“Reviewing your notes can provide insights into your treatment strategies and help you identify areas for improvement,” says Jones.

Massage therapy SOAP notes abbreviations 

Clearly, using SOAP notes provides benefits, both for therapists and clients. But how are they written and structured?

The proper SOAP note format includes four sections. In fact, the name itself, SOAP, is an acronym—with each of the four letters representing a different section of the note.

“The acronym SOAP stands for Subjective, Objective, Assessment, and Plan,” says Jones. 

Let’s further break down each section of massage therapy SOAP notes:

Subjective

When writing SOAP notes for massage therapy, the first section to tackle is the Subjective section.

“In the Subjective section, we capture the client’s description of their condition or concerns,” says Jones.

While the Subjective section of SOAP notes will vary by client and massage therapist, here are some examples of what to include in this section:

• Client’s illness and/or injury history
• Client’s current illness and/or injury presentation
• Client’s complaints
• Client’s current pain level
• Client’s goals for treatment
• Client treatment preferences
• Client’s past experiences with massage
• Direct quotes from the client describing their condition, preferences, and/or goals for treatment (use quotation marks to indicate direct client quotes)

Objective

The next section in massage therapy SOAP notes is the Objective section.

“The Objective section is where we record our professional observations, such as range of motion or tissue condition,” says Jones.

Again, what you include in the Objective section of your SOAP notes will change depending on your client, but some things you might consider adding to this section include:

• Your observations on the client’s current state (for example, their current areas of muscle tension or posture issues)
• Description of therapies and/or modalities performed during a specific session
• Description of the client’s responses to the session 
• Any equipment used during the treatment
• Areas of focus

Assessment

The next portion of massage therapy SOAP notes is the Assessment section.

“The Assessment part is where we interpret the Subjective and Objective information to make a clinical judgment,” says Jones.

In other words, the Assessment section is the portion of the SOAP note where the massage therapist assesses the client’s condition, progress, and response to treatment. 

Elements you may consider incorporating into the Assessment part of your SOAP notes include:

• Your clinical insights into the client’s condition and progress towards established treatment goals
• Any changes, progressions, or regressions from previous sessions
• Client’s response to treatment
• Any pre-existing conditions or injuries that prevented treatment (aka massage contraindication)

If you’re working with insurance, the Assessment section is generally the portion of the SOAP note insurance companies weigh most heavily when making reimbursement decisions—so make sure to be especially thorough, specific, and honest when filling out this section.

Plan

The final section of massage therapy SOAP notes is the Plan—which, as the name suggests, is all about making a future plan for the client’s ongoing treatment.

“The Plan section outlines the treatment approach and goals for future sessions,” says Jones. 

The Plan section of your SOAP notes may include:

• Future treatment plans
• Recommendations for future sessions (including frequency of sessions, duration of sessions, and areas of focus)
• Recommendations for client-directed care in between sessions (for example, stretching or exercise regimens)

Massage therapy SOAP note examples

Still unsure how to write SOAP notes for a massage therapy client? 

Here are some examples of what SOAP notes for massage therapy might look like for various clients:

1. Client experiencing post-accident muscle tension

• Subjective: The client reports persistent neck and shoulder tension following a minor car accident two weeks ago. They describe the pain as constant and tightening, rating it as a 6 out of 10 on the pain scale. The client notes difficulty turning their head and discomfort when sitting at the computer for long periods of time.
• Objective: Upon examination, the therapist observes reduced cervical range of motion and palpates significant tension and tenderness in the trapezius and levator scapulae muscles. Posture assessment reveals forward head posture.
• Assessment: The client’s symptoms and examination findings suggest muscular strain and tension resulting from the car accident, leading to reduced mobility and ongoing discomfort. There are no signs of acute injury requiring medical referral.
• Plan: Recommend a series of six weekly massage therapy sessions focusing on the neck and shoulders, utilizing techniques such as deep tissue massage, myofascial release, and trigger point therapy to relieve muscle tension and improve range of motion. Additionally, suggest stretches for the client to perform at home and ergonomic adjustments to their workstation.

2. Client experiencing chronic lower back pain

• Subjective: The client reports chronic lower back pain for the past year, exacerbated by standing for long periods of time and lifting heavy objects. They describe the pain as a dull ache with intermittent sharp twinges, rating it as a 4 out of 10 on the pain scale. The client mentions occasional numbness in their right thigh.
• Objective: Physical examination reveals tightness and restricted movement in the lumbar spine. Palpation identifies trigger points in the lumbar paraspinal muscles and tightness in the hip flexors. There is no apparent limb length discrepancy or significant postural misalignment.
• Assessment: The client’s history and physical findings indicate chronic lower back pain—likely due to muscular imbalances and trigger points, with possible nerve irritation suggested by thigh numbness. The absence of acute red flags suggests that massage therapy is appropriate.
• Plan: Propose an initial treatment plan of eight bi-weekly massage sessions focusing on relieving muscle tightness in the lower back, glutes, and hip flexors through Swedish massage, trigger point therapy, and stretching techniques. Recommend that the client sees a physical therapist for assessment of thigh numbness and to receive guidance on back-strengthening exercises. Also, sharing recommendations on proper lifting techniques and the importance of taking regular breaks to move and stretch during prolonged periods of standing or sitting.

3. Return client with progression of tension headaches

• Subjective: The returning client reports a noticeable decrease in the frequency and severity of tension headaches since beginning massage therapy four weeks ago. Initially, they experienced headaches three to four times per week, rating the pain as 7 out of 10. Currently, headaches occur one to two times per week with a pain rating of 3 out of 10. The client attributes this improvement to the massage sessions and the relaxation techniques they have been practicing at home.
• Objective: During today’s assessment, the therapist notes improved muscle tone and reduced tension in the upper trapezius and suboccipital muscles, areas previously identified as significantly tight. Range of motion in the cervical spine has increased, particularly in lateral flexion and rotation movements.
• Assessment: The client’s progress indicates that the combination of massage therapy and home practice of relaxation techniques is effective in managing their tension headaches. The reduction in headache frequency and severity, along with improved muscle condition and cervical mobility, suggests a positive response to the treatment plan.
• Plan: Continue with bi-weekly massage therapy sessions, focusing on maintaining the gains in muscle relaxation and further improving cervical range of motion. Introduce more advanced neck and shoulder stretching exercises for the client to practice at home. Discuss the potential benefits of incorporating mindfulness meditation into their routine to help manage stress, which may contribute to tension headaches. Plan to re-evaluate the client’s condition in four weeks to determine if adjustments to the frequency of sessions are warranted.

Tips for using the SOAP note format

Ready to use SOAP notes in your own practice? 

Here are a few tips on how to use massage therapy notes effectively:

Be consistent 

SOAP notes are only effective if you use them on a regular basis—so make sure to be consistent and fill out your SOAP notes every time you see a client. 

“Make it a habit to complete SOAP notes immediately after each session,” says Jones. “This ensures accuracy and helps you stay organized.”

Be specific 

The more detailed and specific massage therapy SOAP notes are, the more effective they are in helping therapists treat their clients. So, when filling out your SOAP notes, make sure to be specific as possible. 

“Use clear, descriptive language in your notes,” says Jones. “Avoid vague terms and be precise in your observations and assessments.”

Be goal-oriented 

People seek out massage for different reasons: some clients may want to use massage as a way to relax, while others are looking to reduce pain. 

It’s important for massage therapists to build treatment plans around those goals—and SOAP notes are a great place to do it. 

“Ensure that your treatment plans are goal-oriented,” says Jones. “This helps you measure progress and keeps the client’s objectives at the forefront of your practice.”

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READ NEXT:

• How to Write a SOAP Note
• What’s the Purpose of SOAP Notes?